Event Notification Report for May 9, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/08/2001 - 05/09/2001
** EVENT NUMBERS **
37970 37971 37972 37973 37974 37975
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|Other Nuclear Material |Event Number: 37970 |
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| REP ORG: NEB DIV OF RADIOACTIVE MATERIALS |NOTIFICATION DATE: 05/07/2001|
|LICENSEE: NEB PUBLIC POWER DISTRICT |NOTIFICATION TIME: 16:22[EDT]|
| CITY: SUTHERLAND REGION: 4 |EVENT DATE: 05/01/2001|
| COUNTY: STATE: NE |EVENT TIME: [CDT]|
|LICENSE#: NE-10-03-03 AGREEMENT: Y |LAST UPDATE DATE: 05/08/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JEFF SHACKELFORD R4 |
| |LARRY CAMPER NMSS |
+------------------------------------------------+SUSAN FRANT NMSS |
| NRC NOTIFIED BY: JOHN FASSELL | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT |
| |
| The event took place at a coal plant where a nuclear gauge is installed on a |
| coal chute. Not following established maintenance procedures led to workers |
| entering the chute with the source exposed. A field of approximately 450 |
| mr/hr was created. Whole body exposure was calculated based on a five hour |
| stay time resulting in an estimate of 2.25 Rem for the most exposed |
| individual. Two other individuals were involved with lower total exposure. |
| |
| |
| The source involved is believed to be Cs-137 with an activity between 100 |
| and 200 mCi. |
| |
| * * * UPDATE ON 05/08/01 AT 1429 ET BY JOHN FASSELL TAKEN BY MACKINNON * * |
| * |
| |
| Four workers were exposed instead of three and all four of the workers were |
| radiation workers for the Neb Public Power District. Calculated whole body |
| radiation exposure to the four workers: 2250 mrem, 1361 mrem, 611 mrem, and |
| 450 mrem. The whole body dose was based on total exposure time multiplied |
| by the maximum measured rate at the beam port, 450 mrem/hr. The individuals |
| were approximately one foot away from the beam port |
| |
| The operations center informed the R4DO (Shackelford) and NMSS EO (Hickey). |
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|Power Reactor |Event Number: 37971 |
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| FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 05/08/2001|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 01:52[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 05/08/2001|
+------------------------------------------------+EVENT TIME: 00:09[EDT]|
| NRC NOTIFIED BY: VEITCH |LAST UPDATE DATE: 05/08/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BRUCE JORGENSEN R3 |
|10 CFR SECTION: | |
|*RPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 22 Power Operation |0 Hot Shutdown |
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| | |
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EVENT TEXT
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| REACTOR WAS MANUALLY SCRAMMED FROM 22% POWER DUE TO FAILURE OF RECIRC PUMP |
| TO RESTART |
| |
| A manual scram was inserted at 0009 on 5/8/01. The scram was conducted in |
| accordance with plant procedures, IOI-8 "Manual Scram," due to a failure of |
| the reactor recirculation pump "A" to restart during a downshift from fast |
| to slow speed operation. Plant response to the manual scram was as |
| anticipated, all rods fully inserted, no ECCS actuations occurred and no |
| SRVs opened. Reactor vessel water level reached Level 3 (177.7 inches) and |
| operators entered the Plant Emergency Instructions. At 0016 the Plant |
| Emergency Instructions were exited. The cause of the "A" recirculation pump |
| failure to restart is being investigated. |
| |
| The NRC Resident Inspector was notified. |
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|Power Reactor |Event Number: 37972 |
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| FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 05/08/2001|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 12:44[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 05/08/2001|
+------------------------------------------------+EVENT TIME: 10:04[EDT]|
| NRC NOTIFIED BY: JIM PRIEST |LAST UPDATE DATE: 05/08/2001|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |WILLIAM COOK R1 |
|10 CFR SECTION: | |
|*SHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| TECH SPEC REQUIRED SHUTDOWN |
| |
| On 5/8/01, at approximately 1004, the Hope Creek Generating Station |
| initiated a unit shutdown to comply with the provisions of Technical |
| Specification (TS) 3.0.3, TS 3.0.3 was entered at 0820 when both trains of |
| the Main Steam Line Isolation Valve Sealing System (MSIVSS) were declared |
| inoperable. The 'B' MSIVSS had been inoperable since 5/4/01 due to a |
| malfunctioning flow transmitter with the associated TS, 3.6.1.4 1 entered. |
| On 5/8/01, at 0508, a Potential Transformer fuse failure associated with |
| the 'C' Class 1E 4.16kV bus tripped two of four channels of Loss of Voltage |
| relay protection for that bus. The tripped channels provide start |
| permissives for the 'C' EDG and have actuated to the tripped condition to |
| provide those permissives. During subsequent investigation of the extent |
| and consequences of the fuse failure, it was determined at 0820 hours that |
| the fuse failure also affected the 'C' Emergency Diesel Generator (EDG) |
| synchroscope rendering the 'C' EDG inoperable due to its inability to meet |
| the surveillance requirement of TS 4.8.1.1.2.h.10 Since the 'C' EDG |
| provides the 1E power to the 'A' MSIV Sealing System both trains of the MSIV |
| Sealing System were considered inoperable and TS 3.0.3 was entered. |
| |
| Investigation into the cause of the fuse failure is ongoing. With the |
| exception of the 'A' Control Room Emergency Filtration System, all other |
| safety-related systems were operable at the time of the event. |
| |
| The licensee notified the NRC resident inspector, the State of New Jersey |
| and Lower Alloways Creek Township. |
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|Hospital |Event Number: 37973 |
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| REP ORG: HENRY FORD HOSPITAL |NOTIFICATION DATE: 05/08/2001|
|LICENSEE: HENRY FORD HOSPITAL |NOTIFICATION TIME: 14:10[EDT]|
| CITY: DETROIT REGION: 3 |EVENT DATE: 04/20/2000|
| COUNTY: STATE: MI |EVENT TIME: 12:00[EDT]|
|LICENSE#: 21-04109-16 AGREEMENT: N |LAST UPDATE DATE: 05/08/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRUCE JORGENSEN R3 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ALAN JACKSON | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION |
| |
| Unintended deviation from a written directive in the use of an |
| investigational temporary brachytherapy implantation device on 04/20/00. |
| Device is the Proxima Therapeutics, GliaSite RTS (a 2-4 cm balloon |
| catheter). The device is being investigated under the NABTT # 9801 |
| Multi-center open label clinical study to evaluate the performance of the |
| Proxima GliaSite RTS in patients with recurrent brain tumors undergoing |
| surgical resection. |
| |
| In this study, the GliaSite RTS is implanted in the tumor resection bed at |
| the time of surgery. Two weeks following surgery, a solution of lotrex and |
| saline is infused into he balloon catheter in order to deliver the radiation |
| dose. Following a specified dwell time, the lotrex is removed from the |
| balloon and the balloon is then surgically removed from the patient's brain. |
| Prior to therapy, radiographic contrast media is infused into the balloon to |
| verify the balloon placement. This contrast media is removed just prior to |
| the infusion to the lotrex. All fluid volumes are tracked to determine the |
| exact volume of fluid in the balloon at all times. |
| |
| In the specific treatment plan where the deviation from the written |
| directive occurred, was prescribed by a Radiation Oncologist and infused |
| into a balloon by a Nuclear Medicine Physician with a dwell time of 70 |
| hours. |
| |
| Following the prescribed dwell time the lotrex was removed and an initial |
| assay of the retrieved lotrex demonstrated a 60% apparent reduction in |
| retrieved activity as compared to the administered activity. The reduced |
| activity measured in the retrieval fluid was to be due to a mixture of |
| contrast media with the lotrex in the fluid. By diluting the retrieved |
| fluid, to remove attenuation characteristics of the contrast media, the |
| total administered activity was measured. |
| |
| Since the contrast media was causing attenuation of the radioactivity in the |
| retrieved fluid, resulting in a reduction of the Dose Calibrator readings, |
| it is assumed the radiation dose to the tissue surrounding the balloon was |
| also reduced. The absorbed dose to the tissue cannot be determined |
| accurately due to the uncertainty in the homogeneity of the iodine-125 and |
| contrast media in the GliaSite RTS during the therapy. Therefore, the |
| attenuation characteristics and absorbed energy within the tissue cannot be |
| accurately modeled. |
| |
| During the investigation of this incident, all steps contained within the |
| Henry Ford Hospital and NABTT #9801 Quality Management Programs were |
| followed. This incident notification of the patient, physicians and all |
| attending staff within 4 hours following the retrieval of the lotrex that an |
| apparent discrepancy in the activity retrieved existed. In addition, all |
| trash and urine were verified to have been retrained and surveys of these |
| waste showed negligible readings. All room surveys also showed no |
| contamination. The patient, as well as fluid retrained from the surgical |
| site and the GliaSite RTS all demonstrated no contamination. The patient |
| was not harmed by the event. |
| |
| To prevent contrast contamination during this therapy in the future an |
| additional flushing of all fluid from the balloon prior to infusion of the |
| lotrex will be done. |
| |
| The NABTT #9801 study is intended as a Phase 1 device trail rather than a |
| clinical efficacy trail. |
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|Power Reactor |Event Number: 37974 |
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| FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 05/08/2001|
| UNIT: [1] [] [] STATE: IA |NOTIFICATION TIME: 18:56[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 05/08/2001|
+------------------------------------------------+EVENT TIME: 16:28[CDT]|
| NRC NOTIFIED BY: BILL CLARK |LAST UPDATE DATE: 05/08/2001|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BRUCE JORGENSEN R3 |
|10 CFR SECTION: | |
|*ESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A N 0 Refueling |0 Refueling |
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EVENT TEXT
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| SPECIFIED SYSTEM ACTUATION |
| |
| "With the plant in a refueling outage, during restoration of the CRD system, |
| ongoing maintenance prevented restoring and opening the scram discharge |
| volume vents and drains. Leakage slowly filled the scram discharge volume. |
| At 1628, level reached the trip setpoint and initiated a RPS trip signal. |
| This is considered a valid initiation signal. All systems responded as |
| expected. No control rod movement occurred and no refueling operations were |
| in progress. Scram has not been reset due to ongoing maintenance." |
| |
| The licensee informed the NRC resident inspector. |
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|Power Reactor |Event Number: 37975 |
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| FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 05/08/2001|
| UNIT: [] [2] [] STATE: TX |NOTIFICATION TIME: 19:24[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 05/08/2001|
+------------------------------------------------+EVENT TIME: 15:28[CDT]|
| NRC NOTIFIED BY: RICK NANCE |LAST UPDATE DATE: 05/08/2001|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JEFF SHACKELFORD R4 |
|10 CFR SECTION: | |
|*RPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
|*ESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A/R Y 100 Power Operation |0 Hot Standby |
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+------------------------------------------------------------------------------+
EVENT TEXT
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| REACTOR TRIP - LOW STEAM GENERATOR LEVEL |
| |
| On 05/08/2001, Unit 2 experienced a automatic Reactor Trip due to low water |
| level in the 2A Steam Generator. Prior to the reactor trip, Instrument and |
| Control Technicians were tuning the 2A Main Feed Water Regulating Valve |
| digital control system. The 2A Main Feed Water Regulating Valve went fully |
| closed, and the Control Room Staff was unable to reopen the valve. |
| |
| At the same time as the Reactor Trip, the Auxiliary Feed Water System |
| actuated due to low water level in the 2A Steam Generator. After the |
| Reactor Trip all Control Rods Fully inserted into the core, all automatic |
| systems operated as designed, and no primary to secondary leakage was |
| detected. |
| |
| The plant is stable in Mode 3, reactor coolant pumps are running and decay |
| heat is being removed by using the main turbine bypass valves. Steam |
| generator water level has been restored and main feed is being used to feed |
| the steam generators. |
| |
| The licensee notified the NRC resident inspector. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021